Complementary Role of Multimodality Imaging in the Evaluation of Intracardiac Lymphoma in an HIV-Infected Man
A 52-year-old homosexual male presented with a 5-month history of anorexia and malaise, a 2-week history of night sweats, pleuritic chest pain, and worsening dyspnea on exertion. A transthoracic echocardiogram to evaluate the cause of his dyspnea revealed significant pericardial effusion with evidence of tamponade physiology, bulky mass (arrowheads) within the coronary sinus (parasternal long axis, Figure 1A, Movie I), and multiple large masses in the right atrium traversing the septum into the left atrium (subcostal, Figure 1B, Movie II). The left ventricular ejection fraction was estimated to be 50%. His blood count showed 5.2×103 white cells/cm3, 39.2% hematocrit, and 279×103 platelets /cm3. Flow cytometry of cells from pericardial tap suggested B-cell lymphoma. He was also found to be HIV positive, with a CD4+ T-cell count of 350/mm3. Cardiac magnetic resonance imaging showed masses in all 4 chambers of the heart, particularly in the right atrium at the interatrial septum and both atrioventricular grooves, with encasement of the left circumflex coronary artery (4-chamber cine, Figure 2A, Movie III). At the 2-chamber cine magnetic resonance (Figure 2B, Movie IV), there was also encroachment of the left atrial appendage. Positron emission tomography revealed irregular foci of increased myocardial uptake of 2-[18F]fluoro-2-deoxy-d-glucose in the right atrium and ventricle (Figure 3). After 1 cycle of R-CDOP (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab), echocardiography showed complete resolution of the pericardial effusion and intracardiac masses (Figure 4). Additional studies showed c-myc 8:14 chromosomal translocation indicative of Burkitt lymphoma. This case illustrates (1) the use of multimodality imaging to evaluate the pathophysiological (echocardiography), structural (magnetic resonance), and metabolic (positron tomography) consequences of this malignancy; (2) diffuse cardiac involvement (with extensive coronary sinus infiltration), which seems to be more common with HIV; and (3) its highly chemosensitive nature, which mandates expedited chemotherapy.
The online-only Data Supplement, consisting of Movies I through IV, is available with this article at http://circ.ahajournals. org/cgi/content/full/115/12/e339/DC1.